Provider Demographics
NPI:1326075771
Name:DIETERLE, JULIE MARY (PT)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:MARY
Last Name:DIETERLE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 S. WHITNEY WAY
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705
Mailing Address - Country:US
Mailing Address - Phone:608-231-3678
Mailing Address - Fax:
Practice Address - Street 1:330 S. WHITNEY WAY
Practice Address - Street 2:SUITE 202
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705
Practice Address - Country:US
Practice Address - Phone:608-231-3678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI953-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
391853394012OtherBLUE CROSS
WI40132500Medicaid